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Human trafficking is an appalling, yet often unspoken about, tragedy that affects more than 14,500 people annually. Read this article to learn about how to recognize a potential victim and, hopefully, save his or her life.

Rosario Sanchez is a critical care nurse at Centrastate Medical Center in Freehold, N.J. She's also a SANE on call for the Monmouth County Prosecutor's Office. Sharon W. Stark is associate dean and coordinator of the nurse practitioner and forensic nursing programs at Monmouth University, N.J.

The authors and planners have disclosed no potential conflicts of interest, financial or otherwise.

It's estimated that 14,500 to 17,500 individuals are trafficked in the United States each year; globally, this crime is a $12 billion industry.1,2 Traffickers sell, trade, and exploit victims using any means of control, subjecting them to isolation, violence, and intimidation. Traffickers may lure victims with empty promises of employment and a dreamlike life, when in reality, victims are forced, defrauded, or coerced into commercial sex or involuntary labor.

Modern day slavery

The United Nations defines human trafficking as:

“The recruitment, transportation, transfer, harboring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation. Exploitation shall include, at a minimum, the exploitation of the prostitution of others or other forms of sexual exploitation, forced labour or services, slavery or practices similar to slavery, servitude, or the removal of organs.”3

The underground nature of this crime must be revealed to the public and healthcare workers, especially forensic nurses who can take a lead role in identifying, interviewing, and advocating for victims.1

Trafficker/victim dynamic, stages

Force, fraud, and coercion are the methods used by traffickers to commit the crime of human trafficking. The process includes attaining and maintaining control of victims for the purpose of servitude, slavery, and debt bondage.4 Force may include rape, beating, captivity, and/or isolation to control the victim. The early period of victimization is often referred to as the “seasoning process” in which the traffickers gain total control through violence.5 Victims are often terrified and succumb at the hands of their traffickers.1

Fraud involves false offers of employment and promises of a better life. For instance, women and adolescents may be promised legitimate opportunities such as marriage, modeling careers, or jobs as a nanny in another country.6 Once they arrive, victims are forced into activities such as sexual slavery, domestic servitude, agricultural labor, sweatshop factory work, and panhandling.1

Coercion often involves threats, debt-bondage (when a trafficker has control of the victim until a transportation fee from another country is paid), and psychological manipulation. A victim may be threatened with injury or death if he or she doesn't comply with the traffickers' demands. Traffickers generally take away all of their victims' travel documents, and keep them isolated to make escape nearly impossible.6 Traffickers use isolation to manipulate victims, making them psychologically vulnerable due to lack of a support system.7 In addition, many victims don't seek assistance or ask for help because they lack the knowledge and/or language to do so. Victims learn survival skills in order to make a better life for themselves at the hands of their traffickers, but at some point victims reach total mental defeat and hopelessness.8

Traffickers work cautiously to entangle victims and secure their dependency. The progression of human trafficking can be described in a couple of stages. The first stage is the “process of initiation.” Traffickers spend time developing the submissive and workable victims who are easier to control.5 The second stage is “indoctrination,” during which traffickers use their authoritarian status to further retain control and build a community with its own rules. Preference may be displayed to some victims within the group to manipulate and retain victims' loyalties.9 (See Table 1.)

Legal framework

In 2000, Congress passed the human trafficking legislation, the Trafficking Victims Protection Act (TVPA), which set forth a clear definition and outlined the differences between human trafficking and smuggling at the federal level. Since its induction, it has been reauthorized to become an affirmative victim-centered law.10

In addition to increasing criminal fines for human trafficking and providing immigration relief to victims, it also created a set of benefits for undocumented victims. As a result, undocumented victims are entitled to the trafficking victim protection visa (T-visa). A T-visa allows trafficking victims the right to live and work in the United States for 3 years, after which they may be eligible to apply for a permanent visa. Under this bill, victims are also eligible for physical and mental health services, housing, food stamps, education, and legal services.10

Many advocates of TVPA support the federal level benefits, but a gap in the legislation still remains at the state level. For example, a sex-enslaved victim may be charged with prostitution when arrested by law enforcement and prosecuted at the state level. Subsequently, the victim is caught in legal limbo as a victim of human trafficking under federal law, but charged with prostitution under state law. Therefore, the creation of state antitrafficking legislation such as the “Safe Harbor” laws are imperative to aid in the investigation and prosecution of traffickers by local and state law enforcement.10 Some states are legislating criminal statutes addressing human trafficking, but much more work is still needed to expose this inhumane crime.

At the international level, the Department of State Office to Monitor and Combat Trafficking in Persons leads the U.S. global commitment to fight against human trafficking. Effective international policies to combat human trafficking include partnering with foreign countries such as Cyprus and Costa Rica.11 The Office to Monitor and Combat Trafficking in Persons supports the fight against human trafficking through its recommendations in the annual Trafficking in Persons (TIP) Report. These recommendations are country-specific. The TIP Report is the U.S. government's diplomatic tool to involve foreign governments in human trafficking issues; it's the world's most complete resource of antihuman trafficking efforts and reflects the U.S. commitment to global leadership on crucial human rights injustice and law enforcement issues.12

Health issues

Human trafficking victims rarely seek medical care. However, when medical care is needed, the ED is often the primary choice for treatment. An ED visit might be the only opportunity to identify victims, meet their immediate needs, and develop a plan with the interdisciplinary healthcare team and law enforcement officials to rescue the victim and hopefully apprehend the trafficker.13

Victims of human trafficking are exposed to numerous health issues. Most victims present with some kind of physical trauma usually resulting from forced manual labor or from direct physical violence by the trafficker or his or her clients in order to control the victim.9 Any form of bodily injury may be a result of extreme physical stress. Cigarette burns, fractures, bruises, contusions, and other burns are common injuries secondary to physical violence.1 Nonetheless, healthcare providers should pay close attention to any bodily injury that doesn't correlate with the history provided by the victim. Many victims have tattoos that clearly brand them to a particular trafficker.14 This might expose victims to infection with hepatitis and other bloodborne diseases.

Also, victims may present to the ED with complaints of a genitourinary and reproductive nature. Adult and children victims of sex trafficking are at high risk for acquiring multiple sexually transmitted diseases, including HIV infection.2 In addition, female victims with their menstrual period may be forced to insert cotton, sponges, or mattress stuffing into their vagina to block menstruation and continue working at the expense of their health. Such practices can cause victims to have abnormal discharges, chronic vaginal and cervical infections, and pelvic inflammatory disease.14

Victims tend to live and work in filthy conditions. Overcrowding and improper sanitation place them at risk for various respiratory and other infections such as tuberculosis. Victims may have food withheld and/or be subjected to inadequate diets, leading them to have physical signs of malnutrition.10

Many of the mental health issues suffered by female victims are due to the frequent psychological abuse at the hands of their traffickers. Female survivors suffer from increased incidences of acute anxiety and stress disorder, depression, and personality disorders, along with low self-esteem, suicidal ideation, disassociation, and poor interpersonal relationships.9

Implications for nursing

Healthcare providers, especially forensic nurses, are one of the few groups of professionals likely to interact with trafficked victims while they're still in captivity.2 Thus, forensic nurses have the best opportunity to screen, identify, intervene, and rescue these victims. Once identified, victims should be referred to support systems where they can obtain important physical and psychological care, as well as material support to enable them to move beyond victimization. One system is the Department of Health and Human Services National Human Trafficking Resource Center; a 24/7 hotline that connects victims of trafficking with local organizations that provide support services.1

As previously mentioned, trafficked victims are likely to suffer a wide spectrum of health risks that reflect the unique circumstances and experiences in a trafficked victim's life. They may have cuts, burns, bruises, and fractured bones, or show signs of anxiety, depression, substance abuse, and malnutrition.7 Victims most often comply and don't attempt to escape or seek help for fear of their safety and/or that of their family members. Threats of harm to family members are one of the most powerful tools used against trafficking victims.

Fear and distrust of all professionals—healthcare providers, government, law enforcement—diminish the possibility of victims seeking help. Traffickers brainwash victims to believe that law enforcement will arrest and deport them. They're told not to say anything to healthcare professionals because of police involvement.10 This isolation allows the trafficker to control the victim's life and sets the stage for total dependency on the trafficker.10

Forensic nurses are in a unique position to build trust with trafficking victims. Taking the time to listen and develop rapport is critical. Suspected victims should always be screened in private to ensure confidentiality and safety, particularly if they appear submissive, hesitant, or fearful of questions. Requesting time alone with a patient shouldn't be done in such a way as to arouse suspicion from the trafficker.7 The person accompanying the victim can be gently asked to assist with paperwork at the front desk. In a sexual assault case, the forensic nurse can ask the person to remain in the waiting room while a specimen is obtained in another room.

It's vital to understand the risk these victims may take by disclosing their plight. An individualized plan of care for the immediate needs of the victim at the particular moment must be implemented.8 This plan must be enacted and understood not only by the healthcare team but also by law enforcement and immigration services. The forensic nurse should be aware of the human trafficking laws at the federal and state level in order to provide victims with possible legal options. The plan must include a coordinated response that can provide safety to the victim as well as the apprehension of the trafficker whenever possible.8 Meeting the victims' physical, mental, and emotional needs must be part of the plan.

Education

Nurses are poorly educated about issues of human trafficking. Most of the education is based in practice experiences if a victim is seen for other health issues. Nursing education programs need to inform students about human trafficking, recognizing victims, and how to intervene on their behalf. Nurses should be wary when the patient isn't allowed to be alone with the healthcare provider; someone else speaks and intervenes in all aspects of care for the patient; there's a language barrier; there are signs of physical and/or mental abuse, malnutrition, anxiety, and/or depression; no documents of identification are available; or the patient doesn't know where they are or live and can't provide information about where they work or what they do.15

Another area where forensic nurses can be very influential is community education to raise awareness of these less obvious victims.9 Topics should include the strengthening of human right laws, prevention practices against human trafficking, the possible physical and mental signs and symptoms the trafficking victims may present with, information about resources available within the community, and culturally sensitive skills. Additionally, because of their background, forensic nurses can educate other nursing colleagues about indicators of human trafficking and teach them assessment skills to screen for signs and symptoms common among trafficking victims.8 The Department of Health and Human Services Office of Refugee Resettlement offers a variety of online Rescue and Restore Toolkits for healthcare professionals to use to identify victims of human trafficking.16

Wake-up call

The business of human trafficking is lucrative for exploiters, and unlike drugs and weapons, victims can be sold over and over for profit. Collaboration is key to creating an effective response team to battle the crime. Sexual assault victim advocates, domestic victim advocates, sexual assault forensic nurse examiners, law enforcement officers, and community social service providers are important members in identifying and assisting trafficked victims.

Forensic nurses need to extend their practice to include research on the field of human trafficking to collect empirical data and continue the development of practices for effective improvement of policies, victims' response, and service model approaches among healthcare providers and law enforcement agents. Future considerations for all healthcare professionals should include education to inspire nurses to join their state's coalition against human trafficking to uncover the hard truth of human trafficking to our nation's blinded eyes.